Еще одна пилюлька Hескучина

[yananshs]

An 83-year-old woman with a history of hypertension and osteoarthritis comes to the office because of abdominal pain with occasional nausea, constipation, muscle weakness, and fatigue over the last 4 months. She denies taking any over-the-counter medications or vitamins. She denies weight changes, change in stool diameter, melena, bright red blood per rectum, or shortness of breath. You notice in her chart that she had a normal colonoscopy 7 months ago. Her temperature is 37.0 C (98.6 F), blood pressure is 120/70 mm Hg, pulse is 73/min, and respirations are 13/min. Physical examination is normal except for mild kyphosis. Her rectal examination is heme negative.

Labs:
RBC 4.2 million per µL
Hemoglobin 7.9 mmol/L
WBC 6 000 per mm3
Platelet 300,000 per mm3

Albumin: 4 g/dl
Alkaline phosphatase: 60 IU/L
ALT (alanine transaminase): 20 IU/L
AST (aspartate aminotransferase): 16 IU/L
BUN (blood urea nitrogen): 10 mg/dl
Calcium - serum: 14 mg/dl
Serum chloride: 105 mmol/L
Creatinine: 1.4 mg/dl
Direct bilirubin: 0.1 mg/dl
Gamma-GT (gamma-glutamyl transpeptidase): 2 IU/L
Glucose: 100 mg/dl
LDH (lactate dehydrogenase): 110 IU/L
Phosphorus - serum: 3 mg/dl
Potassium : 4 mEq/L
Serum sodium: 140 mEq/L
Total bilirubin: 1.0 mg/dl
Total cholesterol: 250 mg/dl
Total protein: 7 g/dl
Uric acid: 5 mg/dl

The most appropriate next step is to
A. determine parathyroid hormone levels
B. determine serum vitamin D levels
C. determine thyroid stimulating hormone levels
D. order a CT scan of the neck
E. order a serum protein electrophoresis